CMS-10433 QHP Certification Instrument Screenshots

OMB Control Number: 0938-1187
Expiration Date: XX/XX/20XX

1/11/22, 11:06 AM

SSM - Interoperability Data

Plan Management

Supplemental Submission

Plan Year: 2023
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10055 - Test Insurance Company - TX

Interoperability Data URL Data
Interoperability Compliance Web Form

 User Guide [PDF, 1.04 MB]

Introduction:
Instructions:
This program attestation will evaluate your compliance with the requirements nalized in the Interoperability and Patient Access Final Rule
published on May 1, 2020. The requirements are detailed in 45 Code of Federal Regulations (CFR) 156.221, and include the implementation and
maintenance of a patient access application programming interface (API) and related documentation.
If you issue plans on the Federally-facilitated Exchanges, including in a state performing plan management functions, submit this form in the
Supplemental Submissions Module (SSM) as part of your Quali ed Health Plan Application in the Health Insurance Oversight System (HIOS). Please
refer to the PY2023 Issuer Instructions for further detail. This form is not required for stand-alone dental plans, Federally-facilitated Small Business
Health Options Programs, and State-based Exchanges on the Federal platform.
You must respond to the questions below to attest to your compliance with each requirement. If you respond "no" to any attestation, you must
submit a narrative justi cation at the end of the form.
Please note: CMS has opted to employ enforcement discretion for 45 CFR 156.221(f), known as the payer-to-payer data exchange provision.
Enforcement of the payer-to-payer data exchange requirement is delayed and will not be incorporated in QHP certi cation for PY 2023. Additional
information on interoperability requirements and enforcement can be found on the QHP Certi cation website:
https://www.qhpcerti cation.cms.gov/s/Interoperability

Attestation and Documentation of Compliance: Patient Access API
The purpose of the following questions is to assess issuer compliance with the requirements of 45 CFR 156.221
as introduced in the Interoperability and Patient Access Final Rule.
* Question 1: Has the issuer fully implemented a secure API that both:
a. Allows all enrollees to access their claims and encounter information through a third-party application of
the enrollee's choice and
b. Meets the standards of Health Level 7® [HL7] Fast Healthcare Interoperability Resources® [FHIR] Release
4.0.1?
Yes
No
* Question 2: Has the issuer ensured inclusion of all information detailed in 45 CFR 156.221(b) in the content
made accessible via the API?
Yes
No
* Question 3a: Has the issuer published on an easily accessible website and/or through publicly accessible
hyperlink(s) information to support third party application use of the API, as detailed in 45 CFR 156.221(d)?
Yes
No
Question 3b: Provide an active URL or URLs demonstrating compliance with Question 3a.
1. Input URL Here
2. Input URL Here

* Question 4a: Has the issuer published educational resources about health information privacy and security,
including the information detailed in 45 CFR 156.221(g), on a website easily accessible to enrollees?
Yes
No
Question 4b: Provide an active URL or URLs demonstrating compliance with Question 4a.
1. Input URL Here
https://pm-test1.insuranceoversight.cms.gov/supplementalsubmission-ui/auth/issuerInteroperability
PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1187, expiration date
is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 24.50 hours per issuer per year, including the time to review instructions, gather the information needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Nicole Levesque at
Nicole.Levesque@cms.hhs.gov.

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SSM - Interoperability Data

2. Input URL Here

Justi cation
If the response to any of the preceding questions was "No" or there was no response provided,
please provide a narrative justi cation that contains the following information:
The date (a single date specifying month, day, and year) by which all referenced
requirements in questions 1-4 will be fully implemented.
A description of how the non-implemented requirements will impact enrollees until such
time as they are fully implemented. Speci cally, detail what functionality, data elements, or
guidance will not be accessible to enrollees until full implementation is achieved. Also,
describe how enrollees currently access all health information maintained by the issuer
until full implementation is achieved.
Details of the root cause for implementation delay and the issuer's plan for completing
implementation by the stated date.
Specify whether the issuer is new to the Exchange for PY 2023.

Input Justi cation Here

Submit

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https://pm-test1.insuranceoversight.cms.gov/supplementalsubmission-ui/auth/issuerInteroperability